Broken Not Crushed living life as a statement, not an apology

A good friend sent me the following from his iPhone last week:

Xn – would you consider this biased or middle of the road on this issue? I found it pretty moderate:

New York Times Editorial: Health Care Reform and You

In my reply, I tried (really, really hard!) to be objective, and un-snarky. If we’re talking about a bill that’s over 1000 pages long (and counting; 300+ pages of amendments), and that radically alters the US economy, we really should be asking some tough questions before we support it. (If that is, we even read the bill.)

And we should GET ANSWERS. Change is not a strategy. The question is, “Is it reasonable to believe that THIS particular change bring about what it promises?”

I tried to bring up questions that I thought the editorial had left unanswered. My questions and comments certainly reflect my worldview; they may reflect ignorance as well. If you have a substantive response to my questions, please comment away!

I’ve included the article in its entirety, with my questions scattered throughout. Here is what I wrote:

Health Care Reform and You

The health care reform bills moving through Congress look as though they would do a good job of providing coverage for millions of uninsured Americans.

Should the goal be providing coverage or improving care or lowering costs? How did we get to the point where you need insurance to afford health care? Is it possible to get back to the place where you don’t? What creative methods are physicians using to lower costs? How many physicians refuse to accept Medicare and other insurance?

How many of the uninsured choose to be so? How many are illegally here?

What other programs (Medi-Cal, Healthy Families, etc.) currently provide services to the poor and uninsured?

HOW MANY PEOPLE CANNOT RECEIVE HEALTH CARE BECAUSE THEY LACK HEALTH INSURANCE? [Hint: none--ask the CEO of any hospital what impact the EMTALA (Federal Emergency Medical Treatment and Active Labor Act) has had on their bottom line. Remember, no bottom line, no hospital.]

But what would they do for the far greater number of people who already have insurance? As President Obama noted in his news conference last week, many of them are wondering: “What’s in this for me? How does my family stand to benefit from health insurance reform?”

Or, “Is this a proper, Constitutional thing to do?”

Many crucial decisions on coverage and financing have yet to be made, but the general direction of the legislation is clear enough to make some educated guesses about the likely winners and losers.

WHAT ARE THE ELEMENTS OF REFORM? The House bill and a similar bill in the Senate would require virtually all Americans to carry health insurance with specified minimum benefits or pay a penalty.

What are the implications for freedom and constitutionality if the Federal gov’t tells private citizens what they must buy with their money?

They would require all but the smallest businesses to provide and subsidize insurance that meets minimum standards for their workers or pay a fee for failing to do so.

What will the “spillover” be on hiring, benefits, and wages? Will workers be working less than full-time so employers can avoid the costs of insurance?

The reforms would help the poorest of the uninsured by expanding Medicaid.

How successful has Medicaid been as a Federally-run health care program? Is expanding it the right approach?

Some middle-class Americans — earning up to three or four times the poverty level, or $66,000 to $88,000 for a family of four — would get subsidies to help them buy coverage through new health insurance exchanges, national or state, which would offer a menu of policies from different companies.

How would private companies, which must make a profit to stay alive, remain competitive with taxpayer-funded companies that don’t have to turn a profit?

IS THERE HELP FOR THE INSURED? Many insured people need help almost as much as the uninsured. Premiums and out-of-pocket spending for health care have been rising far faster than wages.

“Many” is not a scientific number. How many?

What are the root causes for this? Will these change if everyone is insured?

Why have premiums risen faster than wages? Will these causes be mitigated by this approach?

Millions of people are “underinsured” — their policies don’t come close to covering their medical bills. Many postpone medical care or don’t fill prescriptions because they can’t afford to pay their share of the costs.

What other options could defray these costs?

And many declare personal bankruptcy because they are unable to pay big medical debts.

The reform effort should help ease the burdens of many of them, some more quickly than others. The legislation seems almost certain to include a new marketplace, the so-called health insurance exchange. Since there will be tens of millions of new subscribers, virtually all major insurers are expected to offer policies through an exchange. To participate, these companies would have to agree to provide a specified level of benefits, and they would set premiums at rates more comparable to group rates for big employers than to the exorbitant rates typically charged for individual coverage.

How will it be true competition if the insurers are told what their product must cover? How can the rates be less if the coverage is greater? Who defines what rates are “exorbitant” if not the market?

(In my experience, my individual plans have been less expensive than group plans I’ve been on, because insurers can reject applicants based on health.)

Under the House bill, the exchanges would start operating in 2013. They would be open initially to people who lack any insurance; to the 13 million people who have bought individual policies from insurance companies, which often charge them high rates for relatively skimpy coverage; and to employees of small businesses, who often pay high rates for their group policies, especially if a few of their co-workers have run up high medical bills. By the third year, larger businesses might be allowed to shift their workers to an exchange. All told, the Congressional Budget Office estimates that 36 million people would be covered by policies purchased on an exchange by 2019.

So if group policies are high because they get used a lot (that’s what “especially if a few of their co-workers have run up high medical bills” means), then how will this HUGE group policy improve on that?

IS THERE MORE SECURITY FOR ALL? As part of health reform, all insurance companies would be more tightly regulated. For Americans who are never quite certain that their policies will come through for them when needed, that is very good news.

What does this mean? How would this be an improvement over competition in a free market?

The House bill, for example, would require that all new policies sold on or off the exchanges must offer yet-to-be-determined “essential benefits.” It would prohibit those policies from excluding or charging higher rates to people with pre-existing conditions and would bar the companies from rescinding policies after people come down with a serious illness. It would also prohibit insurers from setting annual or lifetime limits on what a policy would pay. All this would kick in immediately for all new policies. These rules would start in 2013 for policies purchased on the exchange, and, after a grace period, would apply to employer-provided plans as well.

How would insurance companies remain competitive in this environment? How have these Federal forays into the market worked in the past? What is the track record?

WHO PAYS? Current estimates suggest that it would cost in the neighborhood of $1 trillion over 10 years to extend coverage to tens of millions of uninsured Americans. Under current plans, half or more of that would be covered by reducing payments to providers within the giant Medicare program, but the rest would require new taxes or revenue sources.

What would be the incentive for a physician to participate in Medicare if his reimbursement rates are cut? What are the current Medicare reimbursement rates? How have those affected costs for other non-Medicare patients? How would this improve that situation?

Are we currently losing doctors? What would provide an incentive for more people to enter the medical field?

If President Obama and House Democratic leaders have their way, the entire tax burden would be dropped on families earning more than $250,000 or $350,000 or $1 million a year, depending on who’s talking. There is strong opposition in the Senate, and it seems likely that at least some burden would fall on the less wealthy.

This is a significant range. It also sounds very close to a middle-class tax increase (“some burden…on the less wealthy”), which President Obama pledged he would not do.

What is the morality of the wealthy paying the bill for this?

What is the incentive for the recipients not to abuse it? How has Medicare fared with fraud, waste, and abuse?

Many Americans reflexively reject the idea of any new taxes — especially to pay for others’ health insurance. They should remember that if this reform effort fails, there is little hope of reining in the relentless rise of health care costs. That means their own premiums and out-of-pocket medical expenses will continue to soar faster than their wages. And they will end up paying higher taxes anyway, to cover a swelling federal deficit driven by escalating Medicare and Medicaid costs.

I’m sorry–I can’t even pretend objectivity in light of this assertion. This is the most stupid, shallow, poor analysis I’ve ever read. IF THIS FAILS THERE IS NO HOPE for cutting costs. Where is the journalism? Where is the analysis of why costs have increased? Fail.

If costs of these programs will continue to escalate ANYWAY, how exactly will this new system improve it? The whole article dies in this paragraph. It not only shows that the author is…uniformed, but also reveals how naked the emperor is and how vacuous these claims are. Gov’t health care, according to this paragraph, has already failed to control Medicare and Medicaid costs.

WHO WON’T BE HAPPY? Healthy young people who might prefer not to buy insurance at all will probably be forced to by a federal mandate. That is all to the good. When such people get into a bad accident or contract a serious illness, they often can’t pay the cost of their care, and the rest of us bear their burden. Moreover, conscripting healthy people into the insured pool would help reduce the premiums for sicker people.

Is it “all” good to force people to buy something they don’t want? Is there another way that might be better, and more respectful of individual freedom? What language in this paragraph shows respect for choice and freedom? “Forced“? “Mandate“? “Conscripting“?

Less clear is what financial burden middle-income Americans would bear when forced to buy coverage. There are concerns that the subsidies ultimately approved by Congress might not be generous enough.

Does this mean the burden on the middle class MAY go up in the future? How much?

Please explain the grammatical propriety of ascribing the word “generosity” to a body that has NOTHING of its own, and gives away only what it takes from others by force. It is not possible for Congress to be generous, anymore than it would be generous of me to give you the keys to my neighbor’s Ferrari.

WHAT IF I HAVE GOOD GROUP COVERAGE? The main gain for these people is greater security. If they got laid off or chose to leave their jobs, they would no longer be faced with the exorbitant costs of individually bought insurance but could buy new policies through the insurance exchanges at affordable rates.

Are there other ways to sever the link between employment and insurance? To make it “portable”? President Bush was mocked for making this suggestion.

President Obama has also pledged that if you like your current insurance you can keep it.

This is only partially true. Read the analysis by Investor’s Business Daily. Page 16 of the bill prohibits insurers from selling any new policies. How will they continue to be competitive and stay in business? Also, if your policy changes at all (as they typically do), you are prohibited from keeping it, as it’s no longer “grandfathered”.

Right now employers are free to change or even drop your coverage at any time.

What market forces prompted employers to offer insurance in the first place (Hint: Eisenhower era wage and price controls)? What market forces compel them to currently offer insurance? How would it harm employers to drop insurance coverage for their employees?

Under likely reforms, they would remain free to do so, provided they paid a penalty to help offset the cost for their workers who would then buy coverage through an exchange. Under the House reform bill, all employers would eventually be allowed to enroll their workers in insurance exchanges that would offer an array of policies to choose from, including a public plan whose premiums would almost certainly be lower than those of competing private plans.

(I’m also free to rob a bank, provided I pay the penalty. That isn’t quite freedom.)

Is it Constitutional to penalize businesses for making business decisions that affect their employees in a private market?

If the public “option” almost certainly costs less, how will private insurers remain in business?

Some employers might well conclude that it is a better deal — for them or for you — to subsidize your coverage on the exchange rather than in your current plan. If so, you might end up with better or cheaper coverage. You would probably also have a wider choice of plans, since most employers offer only one or two options.

WILL I PAY LESS? Two factors could help drive down the premiums for those who are insured. In the short-term, if reform manages to cover most of the uninsured, that should greatly reduce the amount of charity care delivered by hospitals and eliminate the need for the hospitals to shift such costs to patients who have private insurance. One oft-cited study estimates that cost-shifting to cover care for the uninsured adds about $1,000 to a family’s annual insurance premiums; other experts think it may be a few hundred dollars. In theory, eliminating most charity care should help hold down or even reduce the premiums charged for private insurance. When, if ever, that might happen is unclear.

It is not “charity care”. It’s an unfunded mandate. (See EMTALA)

Does this mean that one reason insurance is costly is because those with insurance are subsidizing those without? Isn’t this plan just shifting the subsidization, and not really lowering cost?

If experts can’t agree if the “savings” will be $1000 or $300, how can you make any accurate accounting of savings? That is a HUGE range, especially when it’s unclear when, if ever, it will affect private premiums. If we can’t predict even that component, how much weight should the other projections carry? Is this plan guilty of “Fatal Conceit”?

In the long run, if reform efforts slow the growth of health care costs, then the increase in insurance costs should ease as well. And if the new health insurance exchanges — and possibly a new public plan — inject more competition into markets that are often dominated by one or two big private insurance companies, that, too, could help bring down premiums. But these are big question marks, and the effects seem distant.

Are there truly only one or two private insurance companies? What factors might make it difficult for other companies to compete in the private market? What regulatory hurdles could be lowered or removed?

If it’s bad to have just “one or two” private insurance companies, how will having ONE Federal company, with an unfair competitive advantage over the private insurers, be better?

With all the speculation in this paragraph, is it prudent to make projections?

WILL MY CARE SUFFER? Critics have raised the specter that health care will be “rationed” to save money. The truth is that health care is already rationed. No insurance, public or private, covers everything at any cost. That will not change any time soon.

This is clever but disingenuous. Terms have not been defined. No one has implied that “everything at any cost” is covered now. But nowhere do we have rationing on the scale you see in nations with socialized medicine.

If you lower the cost of something more people will use it. If you lower the supply (less doctors in the profession), and have increased demand, you cannot avoid rationing. As it stands now, a US American can get into a Dr. MUCH faster than someone in Canada or the UK. (watch 20/20 from 7/31/2009 for a well-done John Stossel piece on this.)

It is true that the long-term goal of health reform is to get rid of the fee-for-service system in which patients often get very expensive care but not necessarily the best care. Virtually all experts blame the system for runaway health care costs because it pays doctors and hospitals for each service they perform, thus providing a financial incentive to order excessive tests or treatments, some of which harm the patients.

Which experts say this? What exactly do they say? Are doctors greedy and responsive to a profit motive when they order tests, but not when Medicare reimbursements are cut?

What is being implied about doctors in this paragraph? If doctors are this unethical, how will this program help?

What other factors (besides doctors’ greed) might contribute to “excessive” testing? How have malpractice suits (attorney greed? plaintiff greed?) contributed to the problem?

How will a gov’t manager be able to make a better recommendation than a doctor who has examined the patient?

An earlier wave of managed care plans concentrated on reining in costs and aroused a backlash among angry beneficiaries who were denied the care they wanted. The most expensive treatment is not always the best treatment. The reform bills call for research and pilot programs to find ways to both control costs and improve patients’ care.

How will this be better than a private sector initiative? Isn’t this the goal of any business: to lower costs and improve service? Won’t that attract more business?

The bills would alter payment incentives in Medicare to reduce needless readmissions to hospitals. They would promote comparative effectiveness research to determine which treatments are best but would not force doctors to use them. And they call for pilot programs in Medicare to test the best ways for doctors to manage and coordinate a patient’s total care.

Who decides what is “needless” or “excessive” if it’s not the doctor?

Do doctors not currently seek the best treatments? Aren’t newer treatments necessarily more costly because of the R&D costs? How will this alleviate those costs?

Any changes in the organization of care would take time to percolate from Medicare throughout the health care system. They are unlikely to affect most people in the immediate future.

When? What’s your best guess? Based on what? Is it prudent to vote for something you are in the dark about?

If these changes won’t have much effect in the immediate future, why the rush to get this overhaul passed so soon? Would it be prudent to look at all the options and give everyone a chance to read and digest the bill?

WHAT DOES IT MEAN FOR OLDER AMERICANS? People over 65 are already covered by Medicare and would seem to have little to gain. But many of the chronically ill elderly who use lots of drugs could save significant money. The drug industry has already agreed to provide 50 percent discounts on brand-name drugs to Medicare beneficiaries who have reached the so-called “doughnut hole” where they must pay the full cost of their medicines. The House reform bill would gradually phase out the doughnut hole entirely, thus making it less likely that beneficiaries will stop taking their drugs once they have to pay the whole cost.

Why are Medicare recipients paying for brand-name drugs instead of generics?

Who will subsidize those 50% discounts? What incentive will drug companies have to incur the costs of developing new treatments?

Not everyone in Medicare will be happy. The prospective losers are likely to include many people enrolled in the private plans that participate in Medicare, known as Medicare Advantage plans. They are heavily subsidized, and to pay for reform, Congress is likely to reduce or do away with those subsidies. If so, many of these plans are apt to charge their clients more for their current policies or offer them fewer benefits. The subsidies are hard to justify when the care could be delivered more cheaply in traditional Medicare, and the subsidies force up the premiums for the beneficiaries in traditional Medicare to cover their cost.

It looks like this is saying that private plans will be forced out under this plan. How does “subsidizing” private plans under Medicare differ from (or cost more than) subsidizing everyone, as the current plan proposes? (Interesting that it’s freely acknowledged that subsidies drive up costs for others.)

Reformers are planning to finance universal coverage in large part by saving money in the traditional Medicare program, raising the question of whether all beneficiaries will face a reduction in benefits. President Obama insisted that benefits won’t be reduced, they’ll simply be delivered in more efficient ways, like better coordination of care, elimination of duplicate tests and reliance on treatments known to work best.

If Medicare is currently going broke, and facing a huge unfunded liability, where are these savings going to come from?

What evidence do we have that doctors currently DON’T rely on treatments known to work best?

Is care currently not well-coordinated? How will the Federal gov’t be able to coordinate care better? (The Obama admin couldn’t coordinate the “Cars for Clunkers” program well…how will they be able to do better with health care?)

What demonstrated examples do we have of gov’t coordinating something better than the private sector? Isn’t efficiency/effectiveness/coordination inversely proportional to the layers of bureaucracy involved?

How, based on the fraud and abuse currently evident in gov’t entitlement programs, will THIS entitlement be different?

The AARP, the main lobby for older Americans, has praised the emerging bills and thrown its weight behind the cause. All of this suggests to us that the great majority of Americans — those with insurance and those without — would benefit from health care reform.

This conclusion does not follow from what’s written above. I’m not sure at all that it even suggests a “great majority of Americans” would benefit from THIS type of health care reform. (And according to a recent poll, Americans over 65 oppose this plan 35-47.)

Is this type of utilitarian analysis a good substitute for, “Is it moral?” and “Is it Constitutional?” If a “great majority of Americans” would benefit from pre-emptively locking up people before they commit crimes (think Minority Report), should we do it?

What exactly is the AARP’s expertise in medical matters? What in-depth analysis have they provided? They are a lobbying group, not a doctor or patient group. (Incidentally, I thought Obama had said he thought lobbying groups had too much power and influence and wanted to limit their involvement on Capitol Hill.)

I’m not going to say I think the writer was intentionally biased. I think this piece does show the kind of “intellectual incest” endemic among members of the Mainstream Media (MSM). There is very little real journalism anymore, very little investigation, good questions, fact-finding, questioning, etc.

Right now the MSM is still on the Obama honeymoon and takes what the admin says at face value. They recycle each others’ talking points and call it news. So I don’t think it’s willful bias as much as I think it’s ignorance and obliviousness.

(Like the journalist who commented after Nixon’s election: “How did he get elected? No one I know voted for him!”…Exactly the point!)

For more interesting reading:

The Healthcare Debate’s False Premise
The market is not the problem; we have not yet had a true free market health system

Fact Sheet: America’s Uninsured
The 47 million uninsured number is not quite accurate

Health Care Facts Not In Evidence
How many will still be uninsured AFTER Obamacare?

Should Health Care be considered a “Right”?
How making health care a “right” has actually made the system worse and harmed those it claims to help.